| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,836 |
2,172 |
$264K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,058 |
1,632 |
$165K |
| D0120 |
Periodic oral evaluation - established patient |
3,335 |
3,317 |
$81K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,589 |
820 |
$80K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
885 |
595 |
$75K |
| D1120 |
Prophylaxis - child |
3,024 |
2,994 |
$65K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,713 |
4,018 |
$61K |
| D1206 |
Topical application of fluoride varnish |
3,979 |
3,944 |
$54K |
| D0220 |
Intraoral - periapical first radiographic image |
4,313 |
4,257 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
888 |
872 |
$34K |
| D1351 |
Sealant - per tooth |
1,700 |
663 |
$33K |
| D0330 |
Panoramic radiographic image |
988 |
983 |
$33K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,337 |
1,216 |
$30K |
| D1110 |
Prophylaxis - adult |
991 |
989 |
$29K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
325 |
186 |
$26K |
| D0274 |
Bitewings - four radiographic images |
905 |
905 |
$19K |
| D0272 |
Bitewings - two radiographic images |
1,358 |
1,350 |
$19K |
| D2331 |
|
263 |
181 |
$16K |
| D2332 |
|
226 |
149 |
$16K |
| D2330 |
|
208 |
137 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
577 |
556 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
343 |
328 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
69 |
45 |
$4K |
| D1510 |
|
32 |
26 |
$3K |
| D0350 |
|
92 |
90 |
$2K |
| D2335 |
|
20 |
13 |
$2K |
| D2394 |
|
14 |
12 |
$1K |
| D2950 |
|
14 |
12 |
$1K |
| D3120 |
|
32 |
25 |
$795.00 |
| D9996 |
|
39 |
39 |
$585.00 |